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MPP Pediatric New Patient Intake – 5 to 17 Years Old

Medical History Questionnaire

5 to 17 Years

Demographics

Child’s name *

Adopted/foster care? *

Y

N

Parent names *

Parents married? *

Y

N

Siblings names and ages

Others living in the home

Smokers in household? *

Y

N

School and grade

Sports/Interests

Birth History

Place of birth *

Birth weight *

Problems during pregnancy *

Premature? *

N

Y

If Yes, (How many weeks) *

Birth method

Birth method

Vaginal
C-Section
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Problems after birth?

Name and Location of Prior Medical Provider

Family Health History

(which family member)

Asthma/allergy *

Depression/anxiety/suicide *

ADHD *

Diabetes *

Sudden heart death *

Death before age 50 *

Delayed development *

Serious childhood illness *

Other *

Medications/ Allergies/ Immunizations

Medications

Vitamins/supplements

Medication allergies (specify reaction):

Immunizations up-to-date?

Y

N

Not sure

Personal Health History

(please indicate if your child has a history of any of the following)

Skin *

Cold sores

Eczema

Acne

Allergy/Immune system *

Seasonal/environmental allergy

Food allergy

Anaphylaxis

Seasonal/environmental allergy *

Food allergy *

Anaphylaxis *

Neurologic *

Seizures or epilepsy

Concussion/head injury

Ear, Eye, Nose, Throat *

Trouble seeing/glasses

Lazy eye (strabismus)

Hearing loss

Frequent ear infections

Frequent throat infections

Gastrointestinal *

Reflux disease

Frequent constipation

Cardiac *

Heart disease or surgery

Developmental/Behavioral *

Autism

Speech delay

Attention problems

Depression or anxiety

Other issues *

Respiratory *

Asthma

Pneumonia

Genitourinary *

Urinary tract infection

Other illness

Hospitalizations

Surgery

Full Name *

Email *

Phone *

Areas of Concern

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Office Hours

Monday - 9:00 am-5:00 pm

Tuesday - 9:00 am-5:00 pm

Wednesday - 9:00 am-5:00 pm

Thursday - 9:00 am-5:00 pm

Friday - 9:00 am-5:00 pm

Saturday - By appointment only

Sunday - Closed

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